Urologists now can bill Medicare for prostate cancer screening (G0103), but there is some confusion about which codes to use and when to use them. You must use the correct codes, not only for Medicare but for commercial insurance as well because they often do not accept HCPCS codes, which includes G0103.
There are also times when the urologist uses the test for reasons other than screening. Determining when you are crossing over into a diagnostic test is important for coding and reimbursement purposes.
The American Urological Association (AUA) fought hard for, and won, Medicare reimbursement for prostate cancer screening. As of 2000, Medicare pays for one PSA (prostate specific antigen) test a year if the patient shows no signs or symptoms of prostate cancer. PSA is a tumor marker for adenocarcinoma of the prostate. It is only one indicator of the patient having prostate cancer and is also a useful tool in following the progress of the cancer.
Diagnosis Coding for Medicare
Diagnosis coding can be the trickiest part of billing for a PSA screening. In terms of Medicare, you should use V76.44(special screening for malignant neoplasms; other sites; prostate), says Michael Ferragamo, MD, a urologist and coding expert who practices with Ferragamo, Bruno, Efros, PC in Garden City, N.Y. You must specify that its a screening process. Even though V-codes are notorious for being rejected, Medicare will pay for V76.44 once a year, he says.
You also can use V16.42 (family history of malignant neoplasm; genital organs; prostate) as a secondary diagnosis. You dont really have to use V16.42, since you have to use V76.44 anyway, says Ferragamo. If you are screening someone for prostate cancer, you must use V76.44 for Medicare. But using V16.42 as a secondary diagnosis to V76.44 makes your case for reimbursement stronger.
In addition, some insurance companies will allow you to use 600 (hyperplasia of prostate), not only for a PSA diagnostic test, but for a sonogram of the prostate using CPT code 76872 (echography, transrectal). But, some Medicare carriers will not. Urologists need to check with their local carrier. In any event, once you have detected an abnormality even if it is only an enlarged prostate with no nodule the PSA is no longer a screening test.
Screening means you take a man with a normal prostate, and do a test that will diagnose an inapparent cancer of the prostate, says Ferragamo. Youre doing the PSA as a screen to find an abnormality.
Coding Urinary Disorders
ICD-9 code 600 is not classified as [...]